Download CHIEF COMPLAINT: Followup chronic kidney disease. INTERVAL

The E/M service documented is a
level two hospital progress note.
E/M Insight Case of the Week
99232
$64.76
E/M
History
Exam
MDM
Time
99231
PF
PF
SF/Low
15
99232
EPF
EPF
Mod
25
99233
Det
Det
High
35
(Requires 2 out of 3 key components)
CHIEF COMPLAINT: Followup chronic kidney disease.
INTERVAL HISTORY: The patient's chronic kidney disease
remains stable. His hypertension has been well controlled.
REVIEW OF SYSTEMS: GENITOURINARY: Negative for
flank pain, hematuria, or obstructive symptoms.
PHYSICAL EXAMINATION:
GENERAL: He is awake and alert in no acute distress.
VITAL SIGNS: Show blood pressure of 121/69, respirations
20, and pulse 85.
LUNGS: Clear bilaterally.
CARDIOVASCULAR: Regular rate and rhythm.
ABDOMEN: Soft.
EXTREMITIES: Show no peripheral edema.
History
HPI
ROS
PFSH
PF
Brief
None
None
EPF
Brief
≥1
None
Detailed
Ext
2-9
1/ 3
Comp
Ext
≥ 10
3/3
Exam
Bullets Required
PF
1 - 5 from any organ systems
EPF
6 - 11 from any organ systems
Detailed
≥ 12 from any organ systems
Comp
2 bullets from NINE systems
LABORATORY DATA: Laboratory information shows BUN
of 24, creatinine of 1.3, and potassium 4.1. Hemoglobin 10.1.
IMPRESSION:
1. Chronic kidney disease, which is stable.
2. Hypertension, which is well controlled.
3. Multi-factorial improving anemia.
4. Diabetes with good glycemic control
5. CAD s/p CABG.
MDM
Prob. Pts
Data Pts
Risk
SF
≤1
≤1
Min
Low
2
2
Low
Mod
3
3
Mod
High
≥4
≥4
High
Requires 2/3 dimensions
PLAN:
1. Continue Procrit.
2. Continue current blood pressure medications unchanged.
3. Continue to monitor electrolytes, fluid balance and renal
function while in house.
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